Provider Demographics
NPI:1871917179
Name:KELLY FAMILY ORTHODONTICS
Entity type:Organization
Organization Name:KELLY FAMILY ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:
Authorized Official - First Name:GILLIAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-333-2685
Mailing Address - Street 1:30 MEADOWRUE DR
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-4357
Mailing Address - Country:US
Mailing Address - Phone:207-333-2685
Mailing Address - Fax:
Practice Address - Street 1:30 MEADOWRUE DR
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-4357
Practice Address - Country:US
Practice Address - Phone:207-333-2685
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-07
Last Update Date:2014-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT109491223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty